Medication Administration Errors Result in Elevated Error Rate
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 7.14% based on 28 observed opportunities with 2 errors. In one instance, a resident with type two diabetes mellitus and diabetic neuropathic arthropathy was ordered to receive 15 units of Humalog insulin via pen three times daily. The LPN administering the insulin did not prime the insulin pen and needle by wasting two units prior to injection, contrary to facility policy and standard practice. The LPN stated that she only primes the pen when opening a new one, not with each administration. The facility's policy requires priming the pen with two units before every use to ensure the correct dose is delivered. In another case, a resident with an order for cetirizine 10 mg daily for allergies was instead given loratadine 10 mg by an LPN. The DON confirmed that cetirizine and loratadine are different allergy medications. The facility's medication administration policy requires verification of the right medication, dose, route, time, and resident identity before administration. These failures resulted in the facility exceeding the acceptable medication error rate threshold.